Cardiovascular Institute of Michigan, P.C.	Pt Name «PatientFullName» Address«PatientPrimaryAddressFormatted» DOB «PatientDOB»

Patient Anticoagulation Contract

I have been prescribed Coumadin /Warfarin. I have undergone an education session with written and verbal instructions. I understand why I take Coumadin / Warfarin, how I properly care for and take Coumadin /Warfarin, and the risks involved.

I understand and agree to the guidelines set up by Cardiovascular Institute of Michigan Specifically, the following:

I am aware my INR range is between _____ and _____. I understand I will remain on my prescribed dose until I am contacted by the anticoagulation clinic and I will not change my dose without instruction to do so by the anticoagulation clinic.

I will get my blood drawn to check my INR as instructed by the anticoagulation clinic staff. I will also call the office with any changes in my medical condition, changes in medications and if I have been hospitalized.

I must maintain a current relationship with my physician (at least once a year) to remain in the Coumadin Clinic and to fill my prescription for Coumadin.

All blood draws for INR testing should be performed during the clinics business hours and preferably Monday thru Thursday between 7:00 am and 3:00 pm unless otherwise instructed by the anticoagulation clinic.

I will call Cardiovascular Institute of Michigan at (586)776-8877 for my INR test results 24 hours after having them drawn if I do not hear from the Anticoagulation clinic.

I will report all signs of bleeding and adverse effects promptly or if life threatening bleeding or adverse effects occur or I will go to the emergency room.

I will take Coumadin /Warfarin as instructed and follow the recommendations.

I understand that if I fail to follow these instructions, do not report medication changes and/or do not report to the anticoagulation Clinic for follow up appointments, my doctor, Cardiovascular Institute of Michigan, reserves the right to discontinue monitoring my Coumadin /Warfarin. I will be responsible to find another anticoagulation clinic/ Medical Doctor to follow my Coumadin / Warfarin.

I have received the Coumadin education information and all my questions have been answered.

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